Long-Term Outcome of Surgical Treatment of Penile Fracture Complicated by Urethral Rupture

IntroductionThe combination of lesions of the penile urethra and the corpus cavernosum is rare and is likely to worsen the immediate and long-term prognosis.AimTo assess the late effects of penile fractures complicated by urethral rupture treated by immediate surgical intervention.MethodsFourteen patients with concomitant urethral rupture were treated surgically at our center. Those patients were seen in the outpatient follow-up clinic and were re-evaluated.Main Outcome MeasuresSexual Health Inventory for Men questionnaire, local examination, uroflowmetry and penile color Doppler ultrasound.ResultsThe most common cause of penile fracture is sexual intercourse (50%). The site of tunical tear was in the proximal shaft of the penis in 3 patients (21%) and in the mid of the shaft in 11 patients (79%). Urethral injury was localized at the same level as the corpus cavernosum tear in all cases; and it was partial in 11 cases and complete in 3. Long-term follow-up (mean = 90 months) was available for 12 patients; among whom there was no complications in 4 (33%), painful erection in 1 (8%), erectile dysfunction in 2 (17%), and palpable fibrous nodule in 5 (47%). All patients had a normal urinary flow except one who developed relative urethral narrowing that required regular dilatation for 1 month.ConclusionsThe urethral injury complicating penile fracture is often partial and localized at the level of the corpora cavenosa tear. Standard treatment consists of immediate surgical repair of both urethral and corporal ruptures with no harmful long-term sequelae on urethral and erectile function in most of patients. El-Assmy A, El-Tholoth HS, Mohsen T, and Ibrahiem EHI. Long-term outcome of surgical treatment of penile fracture complicated by urethral rupture.     

The STAGE Technique (Superficial Tunica Albuginea Geometric-Based Excision) for the Correction of Biplanar Congenital Penile Curvature

IntroductionCongenital penile curvature can present with both uniplanar and biplanar defects, the latter of which entails more technically demanding surgery.AimThe study aims to demonstrate the efficacy and safety of our novel superficial tunica albuginea geometric-based excision (STAGE) technique based on multiple, small, superficial elliptical tunica albuginea excisions and geometrical principles for correcting biplanar congenital penile curvature.MethodsThe study represents a retrospective analysis of 145 patients with disabling congenital biplanar ventrolateral (n = 131; 90.3%) or dorsolateral (n = 14; 9.7%) curvature of the penis, which underwent stepwise STAGEs between June 2006 and March 2012. Multiple 3-mm elliptical excisions of the superficial tunica albuginea were performed without compromising the inner layer of the tunica albuginea, thus resulting in a stepwise correction of the curvature and improved distribution of the bending force of the curvature.Main Outcome MeasuresFunctional outcome regarding penile straightening, erectile function, and patient satisfaction were evaluated. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively.ResultsThe mean follow-up period was 21 months (range 6–62 months). Mean age at surgery was 23.8 years (range 15–47 years). Mean degree of curvature was 65° (range 45–90°). There was no recurrent curvature. Complete correction of the penile axis was obtained in 98.6% (n = 143). No change in erectile function according to International Index of Erectile Function-5 score was visible (P = 0.748). The mean loss of penile length was 0.7 cm (range 0.3–0.9 cm). The excellent functional outcomes resulted in a high level of patient satisfaction, including improved self-esteem, libido, sexual intercourse, and psychosexual relief. Two patients had a residual curvature of up to 30° requiring a reoperation. No intra- or postoperative complications were encountered.ConclusionsWe recommend the STAGE technique as the optimal surgical intervention for correcting both uniplanar and biplanar congenital deviations. Kuehhas FE and Egydio PH. The STAGE technique (superficial tunica albuginea geometric-based excision) for the correction of biplanar congenital penile curvature. J Sex Med 2014;11:299–306.     

A New,Innovative, Lengthening Surgical Procedure for Peyronie's Disease by Penile Prosthesis Implantation with Double Dorsal‐Ventral Patch Graft: The “Sliding Technique”

IntroductionPeyronie's disease is the result of the formation of fibrous plaques in the tunica albuginea of the penis; typical presentations of the disease are represented by pain during erection, erectile dysfunction, and penile deformities, such as curvature, narrowing, and penile shortening. The most complex treatment is related to penile shortening.AimTo find a safe procedure in penile shortening due to Peyronie's disease providing a satisfactory lengthening, allowing an early stabilization of the penis, and preventing axial tension on the neurovascular bundles during dilation.MethodsWe describe a new lengthening surgical procedure based on a ventro‐dorsal incision of the tunica albuginea, penile prosthesis implantation, and double dorsal‐ventral patch grafting with porcine small intestinal submucosa. Three patients, affected by Peyronie's disease with penile shortening and erectile dysfunction, underwent this procedure with approval of our local ethical committee.We evaluated the penis lengthening, intraoperative and postoperative complications, patient's preoperative and postoperative sexual life satisfaction (International Index of Erectile Function [IIEF] questionnaire).ResultsThe average operative time was 2 hours and 50 minutes. No major intraoperative nor postoperative complications occurred. No significant bleedings were recorded. Patients were discharged after 48–72 hours.The average increase in length obtained was 3.2 cm. All patients resumed sexual intercourses with satisfaction; no significant loss of sensitivity or any sign of vascular distress of the glans was recorded. The follow‐up is 13 months. The average IIEF score is 60.ConclusionsThe lengthening of the penis by a double dorsal‐ventral patch graft is an innovative procedure that is based on current techniques of plaque incision and grafting, and that can easily resolve severe shortening of the penis due to Peyronie's disease. In the cases presented, this procedure resulted easily, effectively, and safely. Nevertheless, the technique proposed in this article shall be validated through prospective studies with larger samples. Rolle L, Ceruti C, Timpano M, Sedigh O, Destefanis P, Galletto E, Falcone M, and Fontana D. A new, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesis implantation with double dorsal‐ventral patch graft: The “sliding technique.” J Sex Med 2012;9:2389–2395.     

Sexual Function and Tunica Albuginea Wound Healing Following Penile Fracture: An 18-year Follow-Up Study of 352 Patients from Kermanshah,Iran

IntroductionWe present a study on the experiences of penile fracture in an Iranian population.AimTo determine the long-term outcome of penile fracture.MethodsBetween April 1990 and May 2008, 373 patients presented with clinical features suggestive of penile fracture. Of these, 11 declined surgery. The remaining 362 were operated upon using a degloving incision. Ten patients had venous injury and 352 had penile fracture. At follow-up visits, in addition to answering our questionnaire, the patients completed the International Index of Erectile Function (IIEF), Erection Hardness Grading Scale (EHGS), and global self-assessment of potency (GSAP). To enhance documentation and to promote transparency, with the patients' permission, their full name and hospital chart number was sent to the journal.Main Outcome MeasuresClinical findings and IIEF and EHGS scores.ResultsMean patients' age was 29.6 years. Mean duration of follow-up was 93.6 months. Diagnosis was solely clinical. At presentation, 278 (78.9%) reported no pain. Cavernosography, ultrasonography, or magnetic resonance imaging was not used in any of the patients. Penile fracture was due to taqaandan in 269 patients (76.4%). Patients were treated with surgical exploration and repair within 24 hours of admission, regardless of delay in presentation. A nodule was found at follow-up in 330 patients (93.7%). The painless, mostly proximal nodule was palpated at the floor of the corpora cavernosa, in a deep midline position above the corpus spongiosum. The non-expansive nodule was not associated with erectile dysfunction (ED) or Peyronie's disease. Postoperative complications included mild penile pain in cold weather (two patients), transient wound edema (one patient), mild chordee (four patients), and occasional instability of the erect penis (one patient).Postoperatively, of the 217 patients who had partners, 214 (98.6%) were potent. Mean IIEF ED domain score was 29.8 ± 1.1. The EHGS score was 4 in 203 and 3 in 11. The GSAP score was 0 in 204, 1 in 8, and 2 in 2. ED in the remaining three could not be explained by penile fracture. Of 10 nonoperated patients, eight (80%) developed ED.ConclusionPain is rare in penile fracture. Postoperatively, almost all patients develop a permanent, inconsequential, fibrotic nodule. Our time-tested approach provided excellent long-term sexual function. Zargooshi J. Sexual function and tunica albuginea wound healing following penile fracture: An 18-year follow-up study of 352 patients from Kermanshah, Iran. J Sex Med **;**:**–**.     

Erect Penile Length and Circumference Dimensions of 1,661 Sexually Active Men in the United States

IntroductionPenile size continues to receive popular and empirical attention. Little is known about the process of self-measurement and whether the behaviors a man engages in to become erect for self-measurement are associated with his erect penile dimensions.AimsThe article aims to assess men's erect penile dimensions in a study in which the men would presumably be motivated to report accurate information about their penis size; and to explore associations between men's erect penile dimensions, their method of measurement, and their demographics.MethodsData are from an Internet-based baseline phase of a large prospective daily diary study that compared men's use of a standard-sized condom to men's use of a condom sized to fit their erect penis.Main Outcome MeasuresThe main outcomes are participant characteristics, activities engaged in during self-measurement process, and self-reported erect penile length and circumference.ResultsFor this sample of 1,661 men, the mean erect penile length was 14.15 cm (SD = 2.66; range = 4 to 26 cm), and the mean erect penile circumference was 12.23 cm (SD = 2.23; range = 3 to 19). Participant characteristics were not associated with measured length or circumference. Most men measured their penis while alone, using hand stimulation to become erect.ConclusionsIn this sample of men who measured their erect penile length and circumference for the purposes of receiving a condom sized to fit their erect penis, we found a mean erect penile length of 14.15 cm and a mean erect penile circumference of 12.23 cm. The self-reported erect penile dimensions in this study are consistent with other penile dimension research. Also, findings suggest that mode of getting an erection may influence erect penile dimensions. Additionally, how a man becomes erect for self-measurement may be associated with his erect penile length and/or circumference. Herbenick D, Reece M, Schick V, and Sanders SA. Erect penile length and circumference dimensions of 1,661 sexually active men in the United States. J Sex Med 2014;11:93–101.     

Penile fracture seems more likely during sex under stressful situations

IntroductionThe unusual event of penile fracture occurs when there is a disruption of the tunica albuginea surrounding engorged erectile tissue during aggressive sexual behavior. There is often an audible crack and rapid detumescence with subcutaneous hemorrhage that follows.AimsMedical literature has described the etiology and treatment of penile fracture. We report the remarkably unusual social situations of a series of patients who sustained this unique injury.MethodsWe conducted a retrospective chart review of 16 patients whose injury was severe enough to require surgical repair at the University of Maryland between 2007 and 2011. Particular attention was paid to the intake interview in the emergency department and the postoperative chart notes by the attending urologist to ascertain out‐of‐the‐ordinary social situations in which the injury was sustained.Main Outcome MeasuresThe occurrence of penile fracture is sufficiently rare that the author was able to interact personally with most of the patients. The patients were remarkably forthcoming with the personal social dynamics of the sexual encounter.ResultsHalf of these penile fracture patients sustained the injury during an extramarital affair. Only three patients sustained the injury in a bedroom; the remainder was in out‐of‐the‐ordinary locations for sexual intercourse, e.g., cars, elevator, the workplace, and public restrooms.ConclusionsPenile fracture patients appear to be a unique population of men who are having sexual intercourse under stressful situations. Extramarital affairs and out‐of‐the‐ordinary locations appear common in patients sustaining this relatively rare injury. Kramer AC. Penile fracture seems more likely during sex under stressful situations. J Sex Med **;**:**–**.     

ORIGINAL RESEARCH—SURGERY: Seventeen Years' Experience of Penile Fracture: Conservative vs. Surgical Treatment

IntroductionPenile fracture is the rupture of the tunica of one or both corpora cavernosa due to direct blunt trauma to the erected penis. Partial or complete rupture of the urethra or injury to the deep dorsal vein may accompany penile fracture.AimTo compare conservative and surgical treatment modalities in terms of duration of hospitalization, early and late complications such as penile nodule and curvature, erectile dysfunction, and painful erection.Main Outcome MeasuresTreatment results and complications in two groups were evaluated with history and physical examination, and International Index of Erectile Function-5 Questionnaire was used for erectile function assessement.MethodsThe charts of 42 men diagnosed with penile fracture were retrospectively reviewed, and two treatment modalities were compared: conservative (Group I) and surgical (Group II).ResultsBetween 1991 and 2008, a total of 42 patients with penile fracture were followed in our clinic for a mean of 18 months (range: 6–30 months). Five men who refused surgical treatment were treated conservatively, and the other 37 patients underwent surgical treatment. In Group II, the most common complication was painful erection (in 4 of 37 patients, 10.8 %), whereas in Group I, 80 % (4/5 patients) suffered complications such as wound infection, painful erection, penile nodule and curvature, and erectile dysfunction.ConclusionDiagnosis of penile fracture can be based on history and physical examination; diagnostic tests such as ultrasonography and magnetic resonance imaging are generally not required. Fractures must be repaired either immediately or delayed. Because management with emergency surgical repair is the most effective approach, with the lowest complication rate, surgical treatment should be preferred compared to a conservative approach. Yapanoglu T, Aksoy Y, Adanur S, Kabadayi B, Ozturk G, and Ozbey I. Seventeen years' experience of penile fracture: Conservative vs. surgical treatment. J Sex Med 2009;6:2058–2063.     

New plication technique for the treatment of congenital penile curvature

Introduction:  Conditions that cause curvature of the erect penis also lead to difficulties with intercourse. The present study presents an effective surgical treatment for congenital penile curvature.
Methods:  Between March 1996 and August 2004, 49 patients were diagnosed with congenital penile curvature at the Toho University Omori Hospital Reproduction Center, Tokyo. Of these, 27 eligible patients underwent surgical treatment. The operative technique used involved the tunica albuginea being exposed and a number of vertical incisions were made through its superficial layers. The superficial layer of the tunica albuginea was then resected using scissors. Inverted plication sutures were then placed in the raw surface of the corpus cavernosum using 2-0 nylon. In addition, 2-0 polyglactic acid (Vicryl) sutures were placed on either side of each nylon suture knot.
Results:  Of a total of 49 patients, 27 eligible patients underwent surgical treatment with no serious postoperative complications. All 27 patients were able to sustain intercourse. There were no new cases of erectile dysfunction, penile pain or penile shortening. There were no recurrences of penile curvature.
Conclusions:  This new partial thickness shaving, inverted sutures reinforced with dissolving sutures plication method is an extremely effective surgical treatment for congenital penile curvature, with a superior safety profile. (Reprod Med Biol 2005; 4 : 255–258)     

Erect Penile Dimensions in a Cohort of 778 Middle Eastern Men: Establishment of a Nomogram

IntroductionAccurate data regarding the size of the erect penis are of great importance to several disciplines working with male patients, but little high-quality research exists on the subject, particularly in different ethnic groups and for erect penis size.AimThe aim of this study was to create a nomogram of erect penile dimensions in a large sample of Middle Eastern men.MethodsA retrospective cohort study of 778 men (mean age 43.7; range 20–82) attending urological outpatient clinics in Saudi Arabia was conducted. Exclusion criteria were age under 18 years, a presenting complaint of small or short penis, Peyronie's disease or complaint of congenital curvature, clinical hypogonadism, and previous penile surgery or trauma.Main Outcome MeasuresThree erect penile dimensions following induction of erection using intracavernosal injection of Quadrimix.ResultsMean patient body mass index (BMI) was 29.09 (standard deviation [SD] 5.76). The mean suprapubic skin-to-penile tip erect length was 12.53 cm (SD 1.93); the mean erect length from the symphysis pubis to the penile tip was 14.34 cm (SD 1.86); and the mean erect shaft circumference was 11.50 cm (SD 1.74). A nomogram was constructed and statistical analysis performed, demonstrating a weak negative correlation between BMI and erect penile length measured from the suprapubic skin (r = −0.283, P < 0.000) but not from bone to tip, and a weak negative correlation between age and both erect penile length measurements (skin to tip r = −0.177, P < 0.0005; bone to tip r = −0.099, P = 0.006).ConclusionA nomogram for Middle Eastern men can be used as a standard when advising men with small penis anxiety. The importance of measuring erect size and allowing for infra-pubic fat interference in measurement is emphasized. We envisage that this tool can be used to educate and reassure concerned men about the size of their penises. Habous M, Tealab A, Williamson B, Binsaleh S, El Dawy S, Mahmoud S, Abdelwahab O, Nassar M, Mulhall JP, Veale D, and Muir G. Erect penile dimensions in a cohort of 778 Middle Eastern men: Establishment of a nomogram. J Sex Med 2015;12:1402–1406.     

Analysis of the Interobserver Variability in Penile Length Assessment

IntroductionMany men seek penile augmentation treatments—a standard tool for their counseling is to inform them of what is “normal.” Although some studies suggest good correlation between stretched and erect penile length, those that have measured stretched and erect length simultaneously have shown significant variability.AimTo assess the accuracy of differing penile measurements with multiple observers.MethodsWe recruited 201 adult men (mean age 49.6 years) who achieved full erection using intracavernosal injection.Main Outcome MeasuresPenile measurements were taken by one of seven andrology specialists in a private, temperature-controlled (21°C, 72°F) environment. Stretched flaccid and erect length and circumference were measured. We analyzed the accuracy of each flaccid measurement using the erect measurements as a reference, for the overall patient population and for each observer.ResultsThe mean underestimate of length from stretched flaccid to erect was 2.64 cm (21.4%) and girth 2.27 cm (19.5%). Interobserver variability ranged from a mean underestimate of 16–27% (length) and 15–27% (girth).ConclusionsIn this large, multicenter, multi-observer study of penis size, flaccid measurements underestimated erect size. It also seems likely that there is significant interobserver variability. We believe erect penis measurements should be used for men being considered for treatment of small penis anxiety. Habous M, Muir G, Tealab A, Williamson B, Elkhouly M, Elhadek W, Mahmoud S, Laban O, Binsaleh S, Abdelwahab O, Mulhall JP, and Veale D. Analysis of the interobserver variability in penile length assessment.     

Erectile Function Significant Enough for Penetration During Sexual Intercourse after Removal of Inflatable Penile Prosthesis

IntroductionFifty‐two‐year‐old male with history of multiple insults to his erectile tissue, including insertion and removal of penile implant, presents with significant partial erectile function, substantial enough for anal penetration during sexual intercourse.AimErectile function rigid enough for anal penetration, let alone any erectile function after removal of an inflatable penile prosthesis (IPP), is rare. This article, to our knowledge, is the first case of a patient who has undergone multiple insults to his erectile tissue, including an episode of ischemic priapism followed by implantation and removal of an IPP, who presents with erectile function sufficient enough for coitus.Main Outcome MeasuresOutcome measured via standardized patient questionnaires and penile Doppler following injection of Trimix.MethodAn objective measure of the patient's erectile function was performed via penile Doppler.ResultsPenile Doppler after 10‐mcg injection of Trimix revealed numerous perforating vessels from the corpora spongiosum providing blood flow to the corpora cavernosa. The patient obtained approximately 60–70% rigid erection.ConclusionsTo our knowledge, and after thorough review of the literature, we could not find any reports of erectile function significant enough to take part in sexual intercourse and penetration after removal of a three‐piece IPP. The implant usually disrupts the normal anatomy which allows for cavernosal arterial vasodilation and increased blood flow into the corpora. Following dilation of the corpora the cylinders are inserted and inflated, and the smooth muscle that makes up the corpora cavernosum is compressed against the wall of the tunica albuginea. Theoretically, the remaining smooth muscle tissue may retain some of its physiologic function, adding some additional girth to the penis with an already activated IPP during sexual intercourse. Martinez DR, Mennie PA, and Carrion R. Erectile function significant enough for penetration during sexual intercourse after removal of inflatable penile prosthesis. J Sex Med 2012;9:2938–2942.     

The Effect of Condoms on Penile Vibrotactile Sensitivity Thresholds in Young,Heterosexual Men

IntroductionInvestigating the ways in which barrier methods such as condoms may affect penile sensory thresholds has potential relevance to the development of interventions in men who experience negative effects of condoms on sexual response and sensation. A quantitative, psychophysiological investigation examining the degree to which sensations are altered by condoms has, to date, not been conducted.AimThe objective of this study was to examine penile vibrotactile sensitivity thresholds in both flaccid and erect penises with and without a condom while comparing men who do and those who do not report condom-associated erection problems (CAEP).MethodsPenile vibrotactile sensitivity thresholds were assessed among a total of 141 young, heterosexual men using biothesiometry. An incremental two-step staircase method was used and repeated three times for each of four conditions. Intra-class correlation coefficients (ICCs) were calculated for all vibratory assessments. Penile vibratory thresholds were compared using a mixed-model analysis of variance.Main Outcome MeasuresPenile vibrotactile sensitivity thresholds with and without a condom, erectile function measured by International Index of Erectile Function Questionnaire, and self-reported degree of erection.ResultsSignificant main effects of condoms (yes/no) and erection (yes/no) were found. No main or interaction effects of CAEP were found. Condoms were associated with higher penile vibrotactile sensitivity thresholds (F[1,124] = 17.11, P < 0.001). Penile vibrotactile thresholds were higher with an erect penis than with a flaccid penis (F[1,124] = 4.21, P = 0.042).ConclusionThe current study demonstrates the feasibility of measuring penile vibratory thresholds with and without a condom in both erect and flaccid experimental conditions. As might be expected, condoms increased penile vibrotactile sensitivity thresholds. Interestingly, erections were associated with the highest thresholds. Thus, this study was the first to document that erect penises are less sensitive to vibrotactile stimulation than flaccid penises. Hill BJ, Janssen E, Kvam P, Amick EE, and Sanders SA. The effect of condoms on penile vibrotactile sensitivity thresholds in young, heterosexual men. J Sex Med 2014;11:102–106.     

Historical Review of Penile Prosthesis Design and Surgical Techniques: Part 1 of a Three-Part Review Series on Penile Prosthetic Surgery

IntroductionThroughout history, many attempts to cure complete impotence have been recorded. Early attempts at a surgical approach involved the placement of rigid devices to support the natural process of erection formation. However, these early attempts placed the devices outside of the corpora cavernosa, with high rates of erosion and infection. Today, most urologists in the United States now place an inflatable penile prosthesis (IPP) with an antibiotic coating inside the tunica albuginea.AimThe article describes the key historical landmarks in penile prosthesis design and surgical techniques.MethodsThe article reviews and evaluates the published literature for important contributions to penile prosthesis design and surgical techniques.Main Outcome MeasuresThe article reviews and evaluates the historical landmarks in penile prosthesis design and surgical techniques that appear to improve outcomes and advance the field of prosthetic urology for the treatment of erectile dysfunction.ResultsThe current review demonstrates the stepwise progression starting with the use of stenting for achieving rigidity in the impotent patient. Modern advances were first used in war-injured patients which led to early implantation with foreign material. The design and techniques of penile prostheses placement have advanced such that now, more complications are linked to medical issues than failure of the implant.ConclusionsToday's IPPs have high patient satisfaction rates with low mechanical failure rates. Gerard D. Henry. Historical review of penile prosthesis design and surgical techniques: Part 1 of a three-part review series on penile prosthetic surgery. J Sex Med 2009;6:675–681.     

DORSAL Plication Technique for the Treatment of Congenital Ventral Penile Curvature: Long-Term Outcomes of 72 Cases

BackgroundA total of 78 patients aged 11 to 17 years were diagnosed with congenital ventral penile curvature and underwent surgery with the dorsal plication technique between 2005 and 2014.AimTo investigate the long-term outcomes of 72 patients who underwent dorsal penile plication for the treatment of congenital ventral penile curvature without hypospadias.MethodsIn all cases, the intervascular space between the deep dorsal vein and dorsal artery was dissected, and tunical plication was carried out with non-absorbable 3-0 polyamide sutures and the complication and satisfaction rates of the patients were determined in the postoperative seventh year.OutcomesAt the final postoperative follow-up, the patients' satisfaction with the operation was found to be 95.8%.ResultsShortening of the penis (0.5-1 cm) in five cases, recurrence with less than a 20-degree curvature in two cases, palpable sutures in two cases was observed and no patients reported erectile dysfunction.Strengths & LimitationsThe limitations of our study can be considered as the absence of pharmacological erection in the preoperative evaluation, failure to evaluate penile length at the last postoperative follow-up due to the continued development of the penis, inability to evaluate erectile function at the beginning, postoperative erectile capacity being assessed in only some of the operated cases, all operations being performed by a single surgeon in the same center, and the absence of standardized questionnaires for postoperative satisfaction or adverse events.ConclusionAccording to the results of this study, dorsal plication is a relatively simple method with a low risk and high success rate for the treatment of congenital ventral penile curvatures.Akdemir F, Kayıgil Ö, Okulu E. DORSAL Plication Technique for the Treatment of Congenital Ventral Penile Curvature: Long-Term Outcomes of 72 Cases. J Sex Med 2021;18:1715–1720.     

An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures

BackgroundPeyronie’s disease, diabetes, trauma, pelvic surgeries, and aging are conditions that promote penile fibrosis and trigger erectile dysfunction associated with penile reduction. These pathologies require an objective preoperative diagnosis and intraoperative management of penile shrinkage.AimThe goal is to develop a non-grafting procedure to promote lengthening using geometric patterns of multiple staggered small cuts on the tunica albuginea with an optimal ratio between tissue expansion and resistance to confine the cylinders inside the corpora cavernosa.MethodsBetween February 2016 and February 2019, 416 patients suffering penile shortening with or without Peyronie’s disease received implants using the tunica expansion procedures (TEP). Incisions were distributed in respective areas of the tunica to allow maximum expansion while maintaining strength to confine prosthetic cylinders within the corpora cavernosa to prevent bulges and denting.OutcomesIn accordance with these principles, surgical objectives and patient satisfaction were achieved in length and girth restoration regardless of the type of implant used to obtain adequate axial rigidity.ResultsThe sample of 416 patients included 287 cases of Peyronie’s disease having a mean axial deviation of 51° (0–90°) whose curvature was corrected in surgery, with pressure from the cylinders maintaining straightness for malleable and inflatable devices. Tunica constriction in 40.86% of cases was corrected with vertical relaxing incisions. Ventral glanspexy was performed intraoperatively in 92.8% of patients to prevent hypermobility. A penile gain of 3.3 cm (2–6) was measured intraoperatively.Clinical ImplicationsDiagnosis of penile shortening was performed by a stretch length test and pharmacologically induced erection together with the patient’s subjective opinion of penile loss. Lengthening procedure depends on the limit of the dissected neurovascular bundle. The patient and surgeon select the type of implant in accordance with his individual anatomic characteristics.Strengths and LimitationsThe TEP strategy is a non-grafting procedure based on tissue restitution by expansion instead of substitution, which provides surgeons a solution for penile enlargement to the limit of the dissected neurovascular bundle.ConclusionsThe TEP strategy has been demonstrated to be safe and effective to resolve problems of penile size reduction independently of penile curvature. It eliminates grafting and improves penile lengthening techniques using small, staggered cuts on the tunica albuginea, while maintaining tunica structural resistance to contain cylinders inside the corpora, preventing bulges and denting, facilitating tissue regeneration, and improving axial rigidity.Paulo H. Egydio, An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures. J Sex Med 2020;17:2093–2103.     

ORIGINAL RESEARCH–SURGERY: Treatment of Penile Deep Dorsal Venous Leakage of Erectile Dysfunction by Embedding the Deep Dorsal Vein of the Penis: A Single Center Experience with 17 Patients

IntroductionThe common surgery for venous leakage was not very successful; unsatisfactory long-term results have reduced the indications for venous surgery for erectile dysfunction (ED).AimsTo assess the outcomes of embedding the deep dorsal vein of the penis (EDDVP), a new surgical technique used in patients with penile deep dorsal venous leakage of ED.MethodsBetween December 2001 and November 2007, 17 patients diagnosed with penile deep dorsal venous leakage of ED underwent embedding the deep dorsal vein of the penis.Main Outcome MeasuresAll cases were available for follow up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and penile color Doppler ultrasound. Dynamic cavernosography were also assessed in three patients at 3 months postoperatively.ResultsAfter surgery, 14 patients were able to achieve satisfactory intercourse and three had sufficient erection after oral sildenafil (50–100 mg). The IIEF-5 scoring changed from a preoperative mean IIEF-5 score of 8.8 ± 3.9 to 20.8 ± 4.1 (P < 0.05). Peak systolic velocity (average of right and left cavernosal arteries) changed from 41.9 ± 7.7 cm/second to 44.2 ± 9.2 cm/second (P > 0.05), resistance index changed from 0.79 ± 0.1 to 1.00 ± 0.0 (P < 0.05), and venous velocity changed from 8.4 ± 4.0 cm/second to 0.0 ± 0.0 cm/second (P < 0.05). Dynamic cavernosography demonstrated a smooth flow of the deep dorsal vein during the flaccid phase. During the tumescent phase, the deep dorsal vein of the penis was compressed between the dilated sinusoidal spaces and the tunica albuginea and resulted in venous drainage blockade. And then the hardness of erection was improved and maintained.ConclusionsThe new surgical technique of EDDVP is a simple operative procedure, which seems to be efficient in the treatment of penile deep dorsal venous leakage of ED. Zhang B, Chen J, Xiao H, Zhang Y, Cai L, Tao X, Qi T, and Ban D. Treatment of penile deep dorsal venous leakage of erectile dysfunction by embedding the deep dorsal vein of the penis: A single center experience with 17 patients. J Sex Med 2009;6:1467–1473.     

Surgical Management of Penile Fracture and Long‐Term Outcome on Erectile Function and Voiding

IntroductionPenile fracture is an emergency in urology. Surgical management is recommended, but objective data of postoperative long‐term effects, especially regarding voiding and erectile function, vary.AimTo assess long‐term results of patients undergoing surgical therapy for penile fracture.MethodsPatients presenting with suspicion of penile fracture were included in this study. Diagnosis of penile fracture was made by clinical assessment and surgery performed thereafter. The defect of the tunica albuginea was closed by absorbable suture. In case of concomitant urethral lesion, the defect was repaired simultaneously. Voiding and erectile function were evaluated at long‐term follow‐up by mail. Patients' status before penile fracture was assessed retroactively.Main Outcome MeasuresErectile function was assessed by the International Index of Erectile Function questionnaire and voiding function by the International Prostate Symptom Score questionnaire.ResultsN = 34 patients were included. Penile fracture was suspected in 28/34 (82.4%) patients. Twenty‐six of the 28 (92.9%) patients underwent surgery. Only less than half of confirmed fracture patients presented with the classical triad of an audible crack, detumescense, and hematoma. Fourteen of the 26 (53.8%) patients after surgery were available for follow‐up. Mean follow‐up was 45.6 months (range: 3.6–128.4). In 13/14 (92.9%) patients, penile fracture was confirmed by surgery. At follow‐up, 7/13 (53.8%) patients had impaired erectile function, with 3/13 (23.1%) patients needing medical treatment. Four of the 13 (30.8%) patients showed deterioration of voiding including occurrence of urethral fistula.ConclusionsPenile fracture is an emergency for which surgery should be offered. Clinical suspicion of fracture should be high even with hematoma alone. Concomitant urethral injury is common, particularly with bilateral corporal rupture and/or initial hematuria. Preoperative counseling should include discussion of long‐term erectile and voiding dysfunction, penile deformity, and urethral fistula both with and without surgery. Close patient follow‐up is required.     

High Patient Satisfaction of Inflatable Penile Prosthesis Insertion with Synchronous Penile Plication for Erectile Dysfunction and Peyronie's Disease

IntroductionTwenty to thirty percent of patients with Peyronie's disease (PD) have erectile dysfunction (ED) refractory to medical therapy and may benefit from a combined procedure addressing both conditions.AimThe aim of this study was to show the efficacy of inflatable penile prosthesis (IPP) insertion and synchronous penile plication for correcting penile curvature and ED in patients with PD.MethodsA retrospective review was performed of all patients who underwent IPP insertion with synchronous penile plication at our tertiary care center between 2010 and 2013. All patients received an intraoperative saline intracorporal injection to induce an artificial erection. After the tunica albuginea was exposed via a standard transverse scrotal incision over the proximal penile shaft, the incision was retracted distally and/or laterally as needed for plication suture placement. Plication sutures were placed in parallel opposite the angle of greatest curvature. The incision was returned proximally to the standard penoscrotal junction for IPP insertion. Demographic and surgical data were collected from the patients' medical records. Patient satisfaction was assessed postoperatively using a nonvalidated questionnaire.Main Outcome MeasuresThe focus of this study was surgical outcomes, both technical and patient-reported satisfaction.ResultsEighteen patients with a mean age of 63 years underwent IPP insertion with synchronous penile plication. Patients presented with dorsal (n = 11), lateral (n = 2), and biplanar curvature (n = 5). Mean preoperative curvature was 39 degrees (range 30–60) and was corrected on average to <5 degrees (range <5–12) using a median of four plication sutures (range 3–6). Among 15 patients completing a postoperative satisfaction survey at a mean of 11 months, all reported improvement in their overall condition and penile curvature; one with biplanar deformity reported minor residual curvature. None reported continued pain or required suture release.ConclusionsIPP insertion with synchronous penile plication for the correction of ED and PD is effective and results in high patient satisfaction. Chung PH, Scott JF, and Morey AF. High patient satisfaction of inflatable penile prosthesis insertion with synchronous penile plication for erectile dysfunction and Peyronie's disease. J Sex Med 2014;11:1593–1598.     

Inflatable Penile Prosthesis Placement in Men with Peyronie's Disease and Drug-resistant Erectile Dysfunction: A Single-Center Study

IntroductionErectile dysfunction (ED) frequently accompanies Peyronie's disease (PD) and changes the therapeutic approach.AimTo evaluate a single-center experience with inflatable penile prostheses (IPP) in men with medication refractory ED and PD.MethodsNinety men underwent placement of an IPP with straightening maneuvers as necessary to address their deformity and ED.Main Outcome MeasuresPreoperative assessment included International Index of Erectile Function-erectile function domain (IIEF-EF) and duplex ultrasound to confirm ED and measure erect deformity. Postoperative assessment included a modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire, as well as office visits at 1, 6, and every 12 months thereafter.ResultsComplete chart review was performed with mean follow-up of 49 months. Mean preoperative IIEF-EF score was 11. Full rigidity was not obtained in any patient during duplex ultrasound. Mean curvature at maximum erection was 53°. There were seven mechanical failures requiring device replacement, two revision surgeries for pump or reservoir malposition, one infected device, and two corporoplasties for distal tunica erosion. Postoperative office assessment revealed a functionally straight (i.e., <20°) erect penis and a properly positioned as well as operational device in all patients. The modified EDITS questionnaire was returned by 56 (62%). Overall, 84% of patients were satisfied with their outcome, yet only 73% were satisfied with their straightness. Patient perceived postoperative curvature correction stabilized quickly and was complete by 3 months in 84% of patients. Satisfaction with ease of inflation, deflation, and concealability was 84%, 71%, and 91%, respectively. Coital activity was reported by 91% of men in this group.ConclusionIn men with PD and ED, IPP placement allowed reliable and satisfactory coitus for the great majority of men. Mechanical failure was 7%. Men with PD undergoing IPP placement should be counseled regarding potential penile length loss and residual curvature, neither of which appeared to interfere with coitus but may reduce satisfaction. Levine LA, Benson J, and Hoover C. Inflatable penile prosthesis placement in men with Peyronie's disease and drug-resistant erectile dysfunction: A single-center study.